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M C AlraiesM C Alraies 11
Chest Chest Radiography Radiography InterpretationInterpretation
M Chadi Alraies, MDM Chadi Alraies, MDChief Medical ResidentChief Medical Resident
Case Western Reserve University Case Western Reserve University SVCHSVCH
Reading CXR’sReading CXR’s
Have a structured method!Have a structured method!Be consistent with that methodBe consistent with that methodDon’t take short cutsDon’t take short cutsLOOK AT ALL YOUR PATIENTS XRAYS LOOK AT ALL YOUR PATIENTS XRAYS
YOURSELF (and with your resident of YOURSELF (and with your resident of course!)course!)
PRACTICE…PRACTICE… PRACTICEPRACTICE…PRACTICE… PRACTICE
What is a Chest Radiograph?What is a Chest Radiograph?
SHADOWSHADOW
Start at the beginningStart at the beginning
Identification!Identification! Correct patient Correct patient Correct date and time Correct date and time Correct examination Correct examination
Are old films available?Are old films available? DO THIS EVERYTIME – It buys you time and is DO THIS EVERYTIME – It buys you time and is
vitally important.vitally important.
Approach to the CXR: Technical AspectsApproach to the CXR: Technical Aspects
Projection – PA or APProjection – PA or AP Position – Upright or Supine (Supine folks are Position – Upright or Supine (Supine folks are
sick)sick) Inspiratory effortInspiratory effort
9-10 posterior ribs9-10 posterior ribs
PenetrationPenetration thoracic intervertebral disc space just visiblethoracic intervertebral disc space just visible
Positioning/rotationPositioning/rotation medial clavicle heads equidistant to spinous processmedial clavicle heads equidistant to spinous process
ProjectionProjection
Portable (Portable (APAP or Antero- or Antero-posterior)posterior)
FILMFILM
PAPA (Postero-anterior) (Postero-anterior)
FILMFILM
ProjectionProjection
PA AP
Low Lung VolumesLow Lung Volumes
Over ExposureOver Exposure Proper ExposureProper Exposure
9999
Mental BreakMental Break
AnatomyAnatomy
RML
RUL
RUL (Right Upper Lung)RUL (Right Upper Lung)
RML (Right Middle Lung)RML (Right Middle Lung)
RLL (Right Lower Lung)RLL (Right Lower Lung)
Right Sided FissuresRight Sided Fissures
LUL (Left Upper Lung)LUL (Left Upper Lung)
LLL (Left Lower Lung)LLL (Left Lower Lung)
Left Side FissureLeft Side Fissure
LUL
LLL
What to EvaluateWhat to Evaluate
LungsLungsPleural surfacesPleural surfacesCardiomediastinal contoursCardiomediastinal contoursBones and soft tissuesBones and soft tissuesAbdomenAbdomen
Where to LookWhere to Look
ApicesApicesRetrocardiac areas (left and right)Retrocardiac areas (left and right)Below diaphragmBelow diaphragm
Apical TBApical TB
Left Retrocardiac OpacityLeft Retrocardiac Opacity
Normal Anatomy: Frontal CXRNormal Anatomy: Frontal CXR
HeartHeartAortaAortaPulmonary arteriesPulmonary arteriesAirwaysAirwaysDiaphragm/costophrenic sulciDiaphragm/costophrenic sulci
Normal Anatomy: LateralNormal Anatomy: Lateral
HeartHeartAortaAortaPulmonary arteriesPulmonary arteriesAirwaysAirwaysSpineSpine
Maximum x-rayMaximum x-rayTransmissionTransmission
(least dense tissue)(least dense tissue)
Maximum x–ray Maximum x–ray AbsorptionAbsorption
(densest tissue)(densest tissue)
BlackestBlackest
airair
fatfat
soft tissuesoft tissue
calciumcalcium
bonebone
x-ray contrastx-ray contrast
metalmetal
WhitestWhitest
A structure is rendered visible on a A structure is rendered visible on a radiograph by the juxtaposition of two radiograph by the juxtaposition of two different densitiesdifferent densities
Chest Radiography: Basic PrinciplesChest Radiography: Basic Principles
Silhouette SignSilhouette Sign
Loss of the expected interface normally Loss of the expected interface normally created by juxtaposition of two structures created by juxtaposition of two structures of different densityof different density
No boundary can be seen between two No boundary can be seen between two structures of similar densitystructures of similar density
Right Lower Lobe PneumoniaRight Lower Lobe Pneumonia
Differential X-Ray AbsorptionDifferential X-Ray Absorption
The absence of a normal interface may The absence of a normal interface may indicate disease; indicate disease;
The presence of an unexpected The presence of an unexpected interface may also indicate diseaseinterface may also indicate disease
The presence of interfaces can be used The presence of interfaces can be used to localize abnormalitiesto localize abnormalities
Chest Radiographic Chest Radiographic Patterns of DiseasePatterns of Disease
Air space opacityAir space opacity Interstitial opacityInterstitial opacityNodules and massesNodules and massesLymphadenopathyLymphadenopathyCysts and cavitiesCysts and cavitiesLung volumesLung volumesPleural diseasesPleural diseases
LUL PneumoniaLUL Pneumonia
Air Space OpacityAir Space Opacity
Components:Components:air bronchogram: air-filled bronchus air bronchogram: air-filled bronchus
surrounded by airless lungsurrounded by airless lungconfluent opacity extending to pleural confluent opacity extending to pleural
surfacessurfacessegmental distributionsegmental distribution
Air Space Opacity: DDXAir Space Opacity: DDX
Blood (hemorrhage)Blood (hemorrhage)Pus (pneumonia)Pus (pneumonia)Water (edema)Water (edema)
hydrostatic or non-cardiogenichydrostatic or non-cardiogenicCells (tumor)Cells (tumor)Protein/fat: alveolar proteinosis and Protein/fat: alveolar proteinosis and
lipoid pneumonia lipoid pneumonia
Interstitial Opacity: Small NodulesInterstitial Opacity: Small Nodules
Interstitial Opacity: Interstitial Opacity: LinesLines
Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation
Interstitial OpacityInterstitial Opacity
Hallmarks:Hallmarks:small, well-defined nodulessmall, well-defined nodules lines lines
interlobular septal thickeninginterlobular septal thickening fibrosisfibrosis
reticulationreticulation
Interstitial Opacity: DDXInterstitial Opacity: DDX
Idiopathic interstitial pneumoniasIdiopathic interstitial pneumonias Infections (TB, viruses)Infections (TB, viruses)EdemaEdemaHemorrhageHemorrhageNon–infectious inflammatory lesionsNon–infectious inflammatory lesions
sarcoidosissarcoidosisTumorTumor
MassMass
CalcificationCalcification
Well-DefinedWell-Defined
Ill-DefinedIll-Defined
Nodules and MassesNodules and Masses
Nodule: any pulmonary lesion represented in Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameternearly circular opacity 2-30 mm in diameter
Mass: Mass: larger than 3 cmlarger than 3 cm
Nodules and MassesNodules and Masses
Qualifiers:Qualifiers:single or multiplesingle or multiplesizesizeborder definitionborder definitionpresence or absence of calcificationpresence or absence of calcification locationlocation
Right Paratracheal Right Paratracheal LymphadenopathyLymphadenopathy
Right Hilar LANRight Hilar LAN
Right Hilar LANRight Hilar LAN
Left Hilar LANLeft Hilar LAN
Subcarinal LANSubcarinal LAN
*
AP Window LANAP Window LAN
LymphadenopathyLymphadenopathy
Non-specific presentations:Non-specific presentations:mediastinal wideningmediastinal wideninghilar prominencehilar prominence
Specific patterns:Specific patterns:particular station enlargementparticular station enlargement
Cysts & CavitiesCysts & Cavities
Cyst: abnormal pulmonary parenchymal Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air space, not containing lung but filled with air and/or fluid, congenital or acquired, with a and/or fluid, congenital or acquired, with a wall thickness greater than 1 mmwall thickness greater than 1 mm
epithelial lining often presentepithelial lining often present
Cysts & CavitiesCysts & Cavities
Cavity: abnormal pulmonary parenchymal Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in a definitive wall greater than 1 mm in thickness and comprised of inflammatory thickness and comprised of inflammatory and/or neoplastic elementsand/or neoplastic elements
Benign Lung Cyst : Benign Lung Cyst : PCPPCP Pneumatocele Pneumatocele
• Uniform wall thicknessUniform wall thickness• 1 mm1 mm• Smooth inner liningSmooth inner lining
Benign Cavities :Benign Cavities :CryptococcusCryptococcus
• max wall thickness max wall thickness 4 mm4 mm• minimally irregular inner liningminimally irregular inner lining
Indeterminate CavitiesIndeterminate Cavities
• max wall thickness 5-15 mmmax wall thickness 5-15 mm• mildly irregular inner liningmildly irregular inner lining
Malignant Cavities: Squamous Cell CaMalignant Cavities: Squamous Cell Ca
• max wall thickness max wall thickness 16 mm16 mm• Irregular inner liningIrregular inner lining
Cysts & CavitiesCysts & Cavities
Characterize:Characterize:wall thickness at thickest portionwall thickness at thickest portion inner lininginner liningpresence/absence of air/fluid levelpresence/absence of air/fluid levelnumber and locationnumber and location
Pleural EffusionPleural Effusion
Pleural EffusionPleural Effusion
Pleural CalcificationPleural Calcification
Pleural Disease: Basic PatternsPleural Disease: Basic Patterns
EffusionEffusionangle blunting to massiveangle blunting to massivemobilitymobility
ThickeningThickening distortion, no mobilitydistortion, no mobility
MassMassAirAirCalcificationCalcification
Thoracic Aorta AneurysmThoracic Aorta Aneurysm
Chest breast implantsChest breast implants
Rib fx’s
Mediast. OK
Pulmonary contusion
Subcu air
Chest tube
NG tube
MVC victimMVC victim
Deep Right Mainstem IntubationDeep Right Mainstem Intubation
CarinaTip of ET tube
Tip of ET
Pneumomediastinum
wide wide mediastinummediastinum
obliteration of obliteration of aortic knobaortic knob
Rt mainstem Rt mainstem shift up and shift up and rightright
NG deviate NG deviate to rightto right
pleural cappleural cap
Major Vessel Injury
Potential X ray findings
PneumothoracesPneumothoraces
Expiration reduces lung volume, Expiration reduces lung volume, making a small pneumo easier to seemaking a small pneumo easier to see
Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case.
Hodgkin’s Disease
Ao
SVC
Mediastinal Hematoma
Chest tube
NG shift to Rt.
Tracheal deviation to Rt.
ET tubeObliterated aortic knob First rib fx
ET
NG
Rt. Subclavian Art.Lt. Internal Carotid
Artery
Lt. Subclavian Artery
Aortic Rupture
Tension Pneumothorax on CTTension Pneumothorax on CT
Rt. Lt.Mediastinum
Ao
Tension Pneumo
HemothoracesHemothoraces
HemothoraxHemothorax
Supine Upright
Hemopneumothorax
Indistinct diaphragm
Elevated, irregular hemidiaphragm
Close-upClose-upRib fxs
Clavicle fx
Chest tube
Suspicious
Indistinct, elevated diaphragm
Crushed right chestCrushed right chest
After ventilated with PEEPAfter ventilated with PEEP